Archive for the 'Reflections' Category

Fundamentals of Medicine: Diagnosis and Guidance (Not Just Treatment)

Non-clinicians skip over some of the most necessary underpinnings of Doctoring and speak too much about housekeeping issues: Blood Pressure targets, aspirin use, mass screenings, immunization rates and so on.

People without medical degrees could do those things. But there are steps that must be taken before we worry about the measurables. These are the essence of being a physician, what people ask for when they come to see us. Most people don’t come in and say “I need you to regulate my blood pressure” or “Help me lower my cholesterol”. They come in saying “I don’t feel good” or “Help me stay healthy”.


More than anything, people come to us to find out what’s wrong with them. They come with rashes, aches, fevers, coughs, “bunches” (the Maine word for lumps and bumps on their bodies) and concerns like fatigue, which could be a symptom of almost anything.

In that scenario, not to be melodramatic, making a correct diagnosis could be a matter of life or death, or at least wasteful spending of thousands of dollars and valuable time.

We don’t get enough credit by outside observers, like health care administrators, insurers and “consumers” for the value of our diagnostic acumen. It is the first fundamental of health care. Different diseases have different treatments and the success of medical care hinges on treating the right diagnosis.

A trivial example is a patient I heard of just recently with sudden agitation and high blood pressure presenting to the emergency room. Many hours and many tests after arrival – blood tests, EKG, CT scans and so on, he turned out to have urinary obstruction. A Foley catheter relieved the obstruction and cured his high blood pressure as well as his agitation.

A young woman came to see me a few days before graduation for a mild rash on her legs. Not only was she about to graduate; she was also planning a long trip afterward. The bloodwork I ordered STAT on our first encounter showed that she had acute leukemia. She was allowed a temporary leave from the cancer clinic to attend the ceremonies and then went back to continue her treatment. Today, she is the proud mother of a soon-to-graduate teenager. What if I, as she later said, had glanced casually at her skin and sent her off on a faraway trip with a prescription for a cream?


“Treatment”, the second part of the traditional duad, is too simplistic a notion, only useful for lancing boils and prescribing penicillin for strep throat. Most diseases are multifaceted and most patients have several health and disease considerations. Most diseases are also chronic, even ones we thought of as rapidly terminal earlier in our own lifetime, like HIV and an increasing number of cancers.

The physician’s role is not a knee jerk intervention, it is informing and educating the patient and helping each patient choose a plan of action that is right for them.

Primary Care does what Google can’t, it applies knowledge of the patient and of the relative importance of medical facts and factoids and offers guidance in the sense of ranking options.

Even when the treatment requires specialized care we have a role as guides. We help patients choose specialists depending on each patient’s particular medical problems and personal preferences – referral to a particular subspecialty and to a take-charge doctor or a collaborative one, for example.

As guides, we follow patients along on their journey, sometimes actively by showing what to do, sometimes only watching from a distance, ready to intervene if they stumble. We don’t just prescribe, we anticipate – we warn patients and their families of things that may come up at the next turn. It takes experience and expertise do that well, not just handing out mass produced information to meet “meaningful use” mandates.

Sometimes our Guide role requires us to talk about a different journey – not one back to health and function, but one of decline and death. We must be comfortable with that role as well as the cheerleader’s.

The almost pastoral duty we have is to instill and preserve hope. Although this is often for a cure involving certain obstacles or challenges, sometimes the hope we can offer is only the hope of feeling better and sometimes it is just of relief from suffering.

We live in an era of tweets, sound bites and intellectual shortcuts. Medicine doesn’t fit into that kind of mindset very often. Contrary to what some outsiders think, ours is a deeply cognitive profession of careful consideration and deeply personal counsel.

“Treatment” is simply a misnomer for what we do. Even when there is no cure, there is care.

Medicare Knows Everything About My Patients, But Hopes I Will Forget

My clinic belongs to an Accountable Care Organization. My job is to keep my patients medical costs down, in my clinic as well as in the hospital and specialist offices, without sacrificing quality. Of course, I have about zero control over costs generated outside my office.

So, since I can’t do very much about what Cityside Hospital and all the specialists they employ charge for their work, my only chance of getting any “shared savings” is to make my patients look real bad.

That is what some of the Medicare Advantage plans (Federally subsidized for profit contractors who manage Medicare subpopulations that get extra benefits, like glasses and gym memberships, in exchange for Prior Authorizations and other forms of rationing). I used to puzzle over why they paid us $150 just to update/verify my patients problem lists until I got caught up in the same situation through no fault of my own. Now I also know why these lists sometimes contained outrageously erroneous diagnoses such as paraplegia.

The baseline cost, from which any savings (shared savings for my clinic) or the dreaded opposite is calculated, is predicated on complex actuarial formulas, summarized in what Medicare calls Hierarchical Condition Categories.

This is how that works:

Even through Medicare paid for patient X’s medical care in previous years, and received bills with all of his terrible diagnoses listed, they calculate my base “cost” only counting the diagnoses submitted recently. If they don’t see anything that looks expensive, they budget about $8,000 for the coming year for that patient. Never mind that he is a quadriplegic amputee (which I might not include as a reason for any particular visit, although I might treat and code for his bedsores). Of course, since he may need a new power wheelchair anytime, I wouldn’t want that cost to drag down my “performance”, so I’d better put “quadriplegia” and “below-the-knee amputation” on at least one superbill every year.

It seems obvious they hope I’ll forget to “take credit” for how sick Mr. X really is, so that his multiple hospitalizations and new power chair will hurt my clinic’s bottom line.

In other cases, it is more a matter of word choice: If somebody has fairly stable heart disease and takes nitroglycerin two or three times per year, “coronary artery disease” gets me no points, whereas “angina pectoris” jacks up my baseline a little.

Obesity is an interesting problem. If a patient is morbidly obese, that gives me more of this HCC “play money” to work with. Once they lose the weight, I will of course lose those dollars. But there are quality bonuses to be gained from treating obesity. However, Medicare will REJECT any and all claims for office visits conducted solely for the purpose of treating obesity.

There is obviously more money to be made, at least for the next several years, from aggressive coding than from looking over the shoulders of hospitalists and specialists. I can’t even tell from the hospital reports exactly what they did and why they did it. So how and why could I gain more from that than from becoming a Hierarchical Condition Category Coding expert?

This is what I not so fondly call Metamedicine.

(See also The diagnosis codes in that post are the old ICD-9 ones, but the principles still apply.)

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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